Health inspection·August 28, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, interviews, and review of facility policy, the facility failed to ensure the resident personal privacy and confidentiality of medical records was maintained. This affected one resident (#63) of two residents reviewed for medical record release. The facility census was 36. Findings include: Interview with Resident #58's Family Member (FM) on 08/27/25 at 1:32 P.M. revealed she received Resident #58's medical records as requested from the facility, however; it also included another Resident's (#63) personal information, date of birth , insurance, diagnoses, and complete care plan. Review of medical record package sent to Resident #58's FM by facility verified Resident #63's private information and medical information were included in the packet for Resident #58. Interview with the Director of Nursing (DON) on 08/27/25 at 1:15 P.M. verified the medical record requested for Resident #58 also contained Resident #63's personal private and clinical information sent from the facility. The DON also informed Resident #63's family of the breech in confidentiality and release of private information. Review of facility policy titled, Release of Medical Records Policy. dated May 2022 revealed all medical records will be released with a valid request and in accordance with state and federal laws. This deficiency represents non-compliance investigated under Complaint Number 2562366. Residents Affected - Few Page 1 of 2 366342 366342 08/28/2025 St Mary of the Woods 35755 Detroit Road Avon, OH 44011

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 32 out of 36 residents who ate meals in the facility's kitchen. Four residents (Residents #1, #4, #10 and #24) received enteral nutrition and did not receive meals from the kitchen. The facility census was 36. Observations during the initial tour of the kitchen on 08/25/25 from 10:27 A.M. through 10:50 A.M. revealed the wall behind the grill and stove had grease built-up with food spattered, the deep [NAME] shield on the side of the deep [NAME] had half inch thick grease built up. The hood screens above the grill and stove had heavy grease buildup and the stove had burnt food and flood splatter all over it. The shelf under the steam table had grease buildup and food particles, also, the nine casserole dishes on the shelf were dirty with dried food. The reach-in cooler floor was wet with food particles on the floor and water was dripping from the vent on the ceiling, the outside of the cooler had brown fingerprints and liquid and food splatters on it. The shelf where the microwave was had crumbs and grease build-up. The outside of the ice cream freezer was dirty with brown and black spots and there were seven open three-gallon ice cream containers in the freezer with no lids on them. The floor under the prep table and storage area had black buildup and food particles. The walls in the kitchen were dirty with splatters of brown and black liquids and dirty handprints. Interview on 08/25/25 at 10:51 A.M. with Executive Chef #312 verified all dirty areas. Executive Chef #312 verified he did not have a cleaning schedule and does not know when the kitchen is being cleaned. Executive Chef #312 verified the hood screens are to be cleaned weekly but was unable to say when the last time the hood screens were cleaned. Executive Chef #312 verified he did not have any log on when the hood screens were last cleaned. The Executive Chef #312 stated the stove is used and it should be cleaned daily. He verified it did not look like the stove had been cleaned for a while. The Executive Chef #312 verified the kitchen was excessively dirty and needed a good cleaning. The Executive Chef #312 verified the above findings. Review of the facility policy, Kitchen Cleaning Schedules, dated 08/01/21 revealed cleaning tasks are identified and incorporated into a regular schedule. Cleaning schedules include kitchens, serving areas, and dining rooms. Employees are trained on proper cleaning and completion of tasks on the schedule. Hood filters are cleaned weekly. Cabinets and drawers are cleaned as part of a regular schedule and Walls are to be spot cleaned on an as-needed basis and washed yearly. 366342 Page 2 of 2